Welcome to my blog. HIV prevalence is not a reliable indicator of sexual behavior because the virus is also transmitted through unsafe healthcare, unsafe cosmetic practices and various traditional practices. This is why many HIV interventions, most of which concentrate entirely on sexual behavior, have been so unsuccessful.

The question was asked "Should the industries that profit from unhealthy products be viewed as trusted partners and have a seat at the table during public health negotiations?" and the GBCHealth's answer is yes, that "Companies must have a place at the tables where their future is discussed." There's more of this contemptible, self-serving nonsense but I realize some people reading this blog may already be sick enough.

Industries such as big tobacco, big pharma, the massive food industry, genetically modified organisms and others, will stoop to anything that increases their profits and do nothing that threatens their profits in any way. This does not make them part of civil society, it makes them the polar opposite of civil society. To claim that they should have a stake in the discussions is like claiming that the entire military-industrial complex is part of civil society.

While there are many parties working in and around the HIV industry, many of whom probably do fit into the category of civil society, whose work does little more than increase the dependence of sick people on ever increasing quantities of drugs and nothing at all to prevent sickness in those who are still healthy, Gonsalves seems to have his heart in the right place, though just about (for more about ever increasing dependence on drugs, see my Pre-Exposure Prophylaxis blog).

Actually, even even GBCHealth doesn't try to argue that big tobacco is part of civil society. But they do have the cheek to imply that the food industry has played a part in reducing salt and unsaturated fats, or that they will play their part some day. And they argue that if the industry doesn't play a part, who will? Indeed. And that's exactly why they are not a part of civil society.

Gonsalves objects most strongly to the GBCHealth's use of the struggle for treatment rights for HIV positive people in wealthy countries as supporting the point they are making. All the pharmaceutical industry did, and continues to do, is keep their profit margins high and keep increasing the quantities of drugs sold every year. They have even succeeded in persuading Western governments to divert most HIV related funding to the purchase of drugs to the extent that there is little left for preventing HIV.

I am only somewhat behind Gonsalves' contention because there are many parties who are considered, and not just by themselves, to be part of civil society, for example the Gates Foundation and other 'philanthropic' bodies, certain NGOs, much of the UN and various others, who use their 'concern' about HIV and other issues as a platform for promoting their favorite commercial interests. Perhaps civil society itself is already contaminated enough for big business to feel they should also be included?

The models they looked at used exaggerated estimates of the numbers of sex workers, the number of clients, the number of contacts between sex workers and their clients, the percentage of contacts that were unprotected and the number of sex workers and clients who were HIV positive. They also used a very high transmission efficiency figure, which is not borne out by empirical research.

Even using some of the very high figures available, Gisselquist and Correa were not able to account for the estimated number of HIV positive people in India. The claim that almost all HIV is transmitted through heterosexual sex, mainly as a result of commercial sex work, appears to be unfounded. And although estimates of HIV prevalence in India have since been radically revised downwards, it is still vital to identify the main drivers of the epidemic in order to reduce transmission

As is customary in African countries when collecting self-reported sexual behavior data that doesn't match the expectations of the researchers, the information is considered to be unreliable. Perhaps like the models mentioned above, some figures are overestimates and some are underestimates. But, whereas the unreliable data that conforms to the researchers expectations is used to support policy decisions, data from Africans that is said to be unreliable is ignored or scaled up or down, as required to match the expectations.

In the Tanzanian case, not all of the women were sex workers. 58% of them "reported having had one or more casual partners during the past 12 months and approximately 45% reported having received money for sexual favours". But despite the relatively low level of risk, for 68% to become infected, virtually all of them must have been exposed to HIV, perhaps several times. So what kind of exposures did they face? HIV prevalence among men is far lower than it is among women in most parts of Tanzania.

Currently, national HIV prevalence in Tanzania is roughly the same as that among sex workers in India, about 6%. Sex workers in India and ordinarly adults in Tanzania do not face high enough levels of sexual risk to explain high rates of sexual transmission. And only imaginary levels of 'unsafe' sexual behavior and sexual transmission probability could result in 68% of any population being infected through heterosexual sex.

In desperation, the authors suggest that "male clients of female bar workers may function as a bridging group for HIV transmission in the general population". (Notice how these bar workers are assumed to be sex workers, despite evidence to the contrary.) But this kind of model of transmission does not work when trying to explain a generalized epidemic, as Gisselquist and Correa have shown. It only explains a small percentage of transmission. What other risks do people face, not just sex workers?

How many more years will it take before researchers are willing to divert some of their attention from sexual behavior and look carefully at the non-sexual risks that people in developing countries face? Stigma doesn't arise because of lack of understanding about HIV transmission, it arises because the HIV industry insists that 80-90% of the virus is transmitted sexually. The key to reducing HIV transmission and HIV related stigma is one and the same: investigating the relative contribution of various forms of non-sexual risk.

Thursday, October 27, 2011

When something becomes one of the latest media obsessions, it's hard to find anyone criticizing it. That is a problem with crowdsourcing itself: if millions of google hits say it's brilliant it's hard to find the few who say otherwise. But evaluating something like crowdsourcing requires the negative, as well as the positive experiences.

Twitter demonstrates some of the problems. The more you use it, the less valuable it may be to you. If you want to communicate with like-minded people and organizations, you follow them and, hopefully, they follow you. But by the time you follow several hundred the number of communications you receive is far higher than anything you can get through, unless you do nothing else. Others following several hundred are also less likely to be reading tweets, including yours.

So the publicity says "Young people to write new UNAIDS strategy on youth and HIV". I just wonder, if some whippersnapper happens to question the HIV industry orthodoxy about Africans, especially young African females being highly promiscuous, how UNAIDS will respond. Because some have been urging them to investigate this highly racist assumption for years, without any result. Will those taking part share the UNAIDS meme about African sexuality, or will they fight it?

So far, UNAIDS have created a Facebook page. Their CrowdOutAids website just links to this page and there doesn't appear to be a lot going on yet. No doubt there will continue to be rave press releases about the success of the exercise. Again, UNAIDS can afford lots of 'successes'. But will the flabby, overfinanced institution do the one thing it has failed to do for the fifteen years since its establishment, shed light on why HIV transmission is so high among certain groups of people whose sexual behavior is by no means extraordinary?

The report concludes that "Realization of the right to health requires the removal of barriers that interfere with individual decision-making on health-related issues and with access to health services, education and information, in particular on health conditions that only affect women and girls."

Removing laws that criminalize abortion and various types of contraception could allow women access to safe sexual and reproductive healthcare and reduce the use of back street abortion clinics, which threaten the health and lives of women who use them. I say 'could' because it is doubtful if most women in low income countries, where use of such clinics is thought to be highest, have access to safe healthcare of any kind. But if abortion is no longer a criminal offense, the clinics should become less viable.

The need, or perceived need, for an abortion arises from sexual behavior involving males and females. Yet it is the subsequent behavior of the woman that is penalized. Denying women the right to make reproduction-related decisions and failing to provide the requisite health services is discriminatory. As the UN report says, the woman can suffer if she abides by the laws and be punished by law if she does not.

It's heartening to hear a UN agency calling for safe healthcare provision of any kind, not just for sexual and reproductive health. The report includes a call for creating all the conditions, trained personnel, equipment and supplies, etc, that will enable the provision of safe healthcare to those requiring abortion, contraception and other information and services.

The report cites evidence showing that access to family planning can reduce maternal deaths by between 25 and 40% and also reduces the number of unsafe abortions. They even cite the 98% effectiveness of condoms in preventing pregnancy, when used correctly and consistently. This is a figure most of the HIV industry avoid in order to stay in favor with donor country leaders, who need to at least appear to conform to whatever moral orthodoxy keeps them in the driving seat.

This report places welcome emphasis on the provision of accessible and safe health services. It also emphasizes the importance of access to information, the education to act on the information and the autonomy to make informed choices. Removal of criminal laws and legal restrictions is only the first step. I wonder if UNAIDS will read the report.

Because MC would only be likely to have an effect on sexually transmitted HIV, at best, those arguing for its effectiveness must also argue that most HIV is sexually transmitted. The usual array of 'evidence' for this is presented. But not so much of the available literature arguing against this view, also subject to the vagaries of HIV funding decisions, is presented.

Date about infections in children whose mothers are HIV negative, virgins, those who always practice safe sex and various other phenomena are in urgent need of investigation before non-sexually transmitted HIV can be dismissed as almost irrelevant, as it currently is by many researchers.

But there are many questionable claims in the article which it is beyond the scope of a blog post to go into. So I'll just concentrate on a few. Firstly, arguments for MC using the 'mainly heterosexual transmission' assumption are not appropriate to infant circumcision. The fact that infant circumcision is cheaper and more 'convenient' does not alter the need for separate arguments for routine infant circumcision, if such arguments exist.

Secondly, much of the evidence presented for the effectiveness of MC in reducing HIV transmission is similar to data on correlations between low HIV prevalence and high rates of female genital mutilation. Yet, no one is using this evidence to argue for the adoption of such a strategy, thankfully. But HIV rates are often far higher among females than males, so female genital mutilation could be made to seem an even more effective intervention than MC, using similar arguments.

Thirdly, countries with high HIV prevalence may not be ready to carry out so many operations, while at the same time guaranteeing the safety of patients. The article cites some eyewatering claims about numbers of people circumcised in Kenya but also notes that:

"of 81 government health facilities surveyed in Nyanza (the target location of MC services), none had the capacity to implement the full package of voluntary circumcision outlined in the national guidelines. Challenges included lack of a theatre, MC kits and supplies, medical personnel to perform the procedure, and data monitoring tools. Due to this, most of the reported 230,000 circumcisions were done by partner organizations largely in high demand settings using mobile teams."

With those findings in mind, is it credible that less than 1% of HIV transmissions in Kenya and other high prevalence countries results from unsafe injections and blood transfusions combined? Kenya may be a showpiece for mass MC programs but will the sort of money put into these programs also be made available in other countries for the next 10 to 20 years? And what about routine infant circumcision, which proponents also insist on?

It's interesting to pay some attention when reading peer-reviewed articles to the rhetorical tone adopted, the presumptuousness, the triumphalism, the selective use of data and superficial treatment of anything inconvenient, even the self-conscious use of journalese, like "magic bullet", "tool box", "perfect storm" and "surgical vaccine". But there would appear to be a lot of questions remaining to be answered before mass male circumcision programs can safely be scaled up.

Gates has also attached his name to polio 'eradication', another vertical approach, which aims to eradicate a single disease with the exclusive use of vaccines. Polio has been eradicated in countries with good standards of living and modern water, sanitation and hygiene infrastructures and universal access to these social services. Without these, polio is likely to return, as it has in Kenya and several other countries in recent years.

The epidemic area stretches from Nigeria, the most populous country in Africa, down to Democratic Republic of Congo, one of the largest, bordering on over 20 countries. A vaccine for cholera would be great, if and only if people living in these countries also gained access to clean water and sanitation. Without this, eradication will be elusive.

Infection with polio, cholera and malaria, another Gates Foundation 'vertical', even rotavirus and guinea worm, are all related to the conditions in which people live. Providing people with endless vaccinations, pills and powders may be a good way of disbursing the Gates billions and enriching the Gates Foundation's portfolio, but it won't, on its own, eradicate diseases.

Gates and others tinkering in development may put some well publicized resources into water, sanitation and hygiene, but nothing compared to the amount spent on vaccines and other technologies. This only emphasizes the fact that if you target a handful of diseases with pharmaceutical products, polio, guinea worm, malaria and rotavirus for example, you can spend billions and fail to eradicate anything because people rattling with pills still need clean water.

Development has become dominated by a number of highly publicized but often narrow issues, with a big name attached, such as Bill Gates, Bill Clinton, Jimmy Carter, Bono, Buffett and the rest. But the issues are bigger than all of them put together. In just one country in Africa, Tanzania, neither the biggest nor the most populous, it would take substantial amounts of money to provide everyone with adequate water and sanitation and to provide them with housing that is not a breeding ground for the biggest killers of all, water-borne diseases, acute respiratory infections and a few others.

But it would take more than money. The aforementioned egos would need to cooperate with the people of Tanzania and the Tanzanian government, rather than just imposing their clever schemes from above. They might then notice that Tanzania is not a big bunch of sick people looking for a 'cure', but a population with basic human needs, food, water, shelter and the like.

Ensuring that people don't suffer from easily prevented diseases by providing them with basic human needs is the 'grand challenge' that will not be met as long as it is not a target. Barriers to development, and there are many, will also need to be removed. But some of those barriers involve large scale marketing of pharmaceutical and other products to unsuspecting people, which appears to be the source of much of the Gates Foundation's funding. Far from being a big player in development, the Foundation may be one of the biggest beneficiaries of underdevelopment. It's sustainable, but is sustaining underdevelopment what we want?

Buffett (senior and junior), Gates (Mr and Mrs), the
Rockefeller Foundation and various other well heeled parties with long
experience of interfering in developing countries are all involved in an
elaborate front for the GMO industry called AGRA, the Alliance for a Green
Revolution in Africa. They have even recruited a few Africans to give
themselves a bit of street-cred.

While Buffett junior points out that soil is more important
than seed, he fails to mention that there isn't a shortage of food globally,
nor even in some of the areas that are experiencing starvation and famine.
There is a lack of access to food because people are poor and food supply is
controlled by rich people, who can sit on surpluses until the price goes up to
a level they feel is worth selling for.

It must have been an odd experience to hear Buffett making
such statements about GMOs with representatives from Monsanto, and even AGRA,
present. But given that Monsanto has 'donated' seed, genetic materials and
other agricultural inputs to recipients of AGRA's largesse, this sounds like
part of a 'softly, softly' approach to shoving GMOs down people's throats,
whether they like it or not.

It's interesting that Buffett speaks from his own experience
of growing GMOs in the US, pointing out some of the drawbacks that the industry
have spent years denying and trying to cover up. But telling the truth against
such a sustained background of lies doesn't mean that AGRA have some honorable
intentions, in addition to their desire for world domination for high tech
agriculture and food production companies.

Friday, October 14, 2011

The Lancet's article 'Assessment of population-level effect of Avahan, an HIV-prevention initiative in India' makes interesting reading, not least because most HIV prevention 'initiatives' appear to be assessed in a cursory manner, as if all effort goes into finding good news and burying bad news. The researchers go to great lengths to present figures and analyses that would allow anyone to judge the merits of Avahan themselves.

But behind the hype, and even The Lancet article seems to accentuate the positive, what the researchers found was a rather small effect with a very large margin of error. While you would expect a set of interventions to have some effect, as opposed to none at all, this project involved a very large investment over a relatively long period of time.

There are two reservations I have about this study, the first being my overall reservation about HIV prevention interventions; HIV is not all, perhaps not even mainly, sexually transmitted. While this program also targeted risk groups who face non sexual risks, such as intravenous drug users, author Lalit Dandona tells the Times of India "HIV mainly spreads in India through sexual intercourse".

My second reservation is the contention that "interventions like safe-sex counselling by peers, treatment for sexually transmitted infections, distribution of free condoms and needle and syringe exchange programmes among the most-at-risk population prevented the virus from spreading among the general population" (my emphasis); I don't believe that HIV spreads, to any substantial extent, from 'high risk' populations to the general population.

Consider the high prevalence groups in African countries, such as Kenya. They are not 'high risk' populations in the sense HIV researchers use, they are not primarily sex workers, men who have sex with men, intravenous drug users or even truckers. The mystery UNAIDS doesn't like to acknowledge is how people who don't have 'high risk' behaviors can have such high HIV prevalence, considering how slowly HIV spreads through penile-vaginal sex.

High prevalence groups, such as members of the Luo tribe in Nyanza province, do not appear to 'spread' HIV throughout the country, not even to the neighboring people of the Kuria and Kisii tribes or those of the Luhya tribe in the province just North of Nyanza, where HIV prevalence is far lower. The population of Nairobi and other high population density areas do not 'spread' HIV to low population density areas.

While prevalence among Luhya overall is far lower than that among the Luo, prevalence among Luhya women is far higher than it is among men. As a high prevalence group, Luhya women don't even appear to 'spread' HIV among Luhya men very efficiently. There are 10 infected Luhya women for every 1.7 infected men. Many high HIV prevalence groups do not have identifiably high sexual risk behaviors.

Treatment of sexually transmitted infections, while important in its own right, has not been shown to have much impact on HIV transmission. Similar remarks apply to distribution of free condoms; condoms do protect against HIV transmission, but only sexual transmission. And needle exchange programs do reduce HIV transmission among intravenous drug users (though perhaps not as effectively as is sometimes claimed). But these 'high risk' groups have never been demonstrated to 'spread' HIV among the general population.

As the opening sentence of The Lancet paper says "The aim of Avahan...was to reduce HIV transmission in the general population through large-scale prevention interventions focused on high-risk groups." Sex workers, their clients and their clients' partners, intravenous drug users and their partners all together don't account for a large proportion of HIV transmissions in countries where Modes of Transmission Surveys have been carried out.

While much has been made by the media about men who have sex with men also having sex with women, it has not been shown that this plays a significant role in 'spreading' HIV from this group to the general population. The number of men who have sex with men also having sex with women is unlikely to be very high, so the number of women involved is also going to be low. This phenomenon is probably far more significant in the minds of journalists (and possibly researchers) than it is in the real world.

The research does not show any mechanism by which HIV prevalence somehow radiates out from 'high risk' groups to the general population through sexual behavior. Nor does it shed any light on how people who only face low sexual risk levels are infected at higher rates than could be expected. It would be disturbing if the several thousand dollars per infection 'averted' failed to avert any infections, but it is unlikely that the number is anywhere near 100,000.

With HIV, it appears that 'high risk' does not always result in high prevalence, and high prevalence has not always been explained by high risk levels. This is a serious anomaly and HIV research that fails to account for it will be flawed at best, totally invalid at worst.

Wednesday, October 12, 2011

Why do so many HIV-positive children in Africa have HIV-negative mothers? For example, approximately 30% of HIV-positive kids aged 0-11 years have HIV-negative mothers in Mozambique (see pp. 177-181 in: http://www.measuredhs.com/pubs/pdf/AIS8/AIS8.pdf)

Why are so many virgin men and women found with HIV? In the Republic of Congo, for example, virgin women aged 15-49 years have higher HIV prevalence than all women, 4.2% vs 4.1%(see p. 101 in: http://www.measuredhs.com/pubs/pdf/AIS7/AIS7.pdf)

The personal stories behind these statistics are hard to fit with the common view that almost all infections are from sex. Why has there been so little attention and response to Africans with unexplained infections?

THE PURPOSE OF THIS NOTE IS TO INITIATE DEBATE ABOUT WHETHER TO CONTINUE TO IGNORE NON-SEXUAL HIV INFECTIONS IN AFRICA.

To do so, this note presents four arguments for AIDS activists, both in Africa and elsewhere, to recognize and respond to HIV from skin-piercing procedures in African health care and cosmetic services.

1. DE-STIGMATIZING HIV/AIDS: Programs for HIV prevention in Africa – including especially foreign-funded programs -- focus almost exclusively on sex. With all attention on sex, the emotions, prejudices, and controversies around sex naturally spill over into HIV programs. Thus, it is not only wrong to think that all African HIV comes from sex (see points 3 and 4, below), but also confusing and distracting. Currently, stigma against HIV is so great that most people with unexplained infections keep silent, so as not to be accused of sexual behaviors that some people don’t like. When the public discourse is corrected to recognize blood-borne as well as sexual HIV (see: http://dontgetstuck.wordpress.com), people with HIV from blood risks will be able to speak out without facing stigma compounded by charges they are lying. And they will then be able to contribute to public efforts to make health care and cosmetic services safe.

2. PREVENTING HIV INFECTIONS: Ensuring that medical facilitiesare safe will not only prevent HIV infection but also the transmission of other blood borne pathogens. Across Africa, HIV prevalence is lower in countries where more people are aware of blood-borne risks for HIV; see: http://dontgetstuck.wordpress.com/africans-aware-of/

3. SEX ALONE CAN’T EXPLAIN AFRICA’s HIV EPIDEMICS: All attempts to explain Africa’s epidemics as exclusively sexual have failed to find anything that is so different about sex in Africa that could account for Africa’s high rates of HIV prevalence. Studies find that Africans have fewer partners and use condoms more than Americans and Europeans.Circumcision is less common in Europe than Africa. Sex can’t explain how HIV prevalence is lower after long term wars, and among people living further from health clinics. Sex is a risk for HIV because so many Africans are infected – but how are so many infected?

4. EVIDENCE THAT AFRICANS GET HIV FROM SKIN-PIERCING EVENTS: A lot of evidence shows HIV transmission through skin-piercing procedures in Africa. Evidence is both old and new. For example:

(a) In 1985, Project SIDA in Kinshasa, Zaire (now the Democratic Republic of Congo), tested inpatient and outpatient children aged 1-24 months and their mothers for HIV. Seventeen (39%) of 44 HIV-positive children had HIV-negative mothers. Among children with HIV-negative mothers, “medical injections seemed to be the most important risk factor for HIV…” The study team noted, “Injections are often administered in dispensaries which reuse needles and syringes yet may not adequately sterilize them” (Mann et al, Risk factors for human immunodeficiency virus seropositivity among children 1-24 months old in Kinshasa, Zaire. Lancet 1986, ii: 654-7. p. 656.)

(b) Around 1990, WHO’s Global Programme on AIDS coordinated a study in Rwanda, Uganda, Tanzania, and Zambia to test in-patient children 6-59 months old and their mothers for HIV. Sixty-one (1.1%) of 5,593 children were HIV-positive with HIV-negative mothers; only three had been transfused. WHO experts concluded “the risk of non-perinatally acquired HIV and of patient-to-patient transmission of HIV among children in health care settings is low” (Global Programme on AIDS. 1992-1993 Progress Report. Geneva: WHO, 1993). A similar conclusion would be unthinkable if 1% of inpatient children in London, Boston, or Seoul were found with non-vertical HIV infections.

(c) A study among women in Malawi, 2003-05, found that women who had received hormone injections for birth control were 10.4 times more likely than other women to return with incident HIV infections, and 23 of 27 women with incident infections had received such injections; relative risk was adjusted for age, bacterial vaginosis, and number of sexual partners; reported condom use was uncommon for both women who acquired HIV infection (11.5%) as well as for those who remained HIV-negative (15.1%) (Kumwenda et al. Natural history and risk factors associated with early and established HIV type 1 infection among reproductive-age women in Malawi. Clin Infect Dis 2008; 46: 1913-1920).

The top five are vaccines, infant male circumcision, prevention of mother to child transmission, making blood transfusions safe and scaling up antiretroviral treatment. Vaccines don't exist yet. But assuming that when they do they will actually be used where they are most needed, unlike most health resources, they might have some impact.

Mother to child transmission has been very successful in rich countries but in poor countries, and all high HIV prevalence countries are poor when it comes to health spending and quality, the women who are infected with HIV should never have been in the first place. Many of them didn't get HIV from their sexual partner and the main risks they face are probably non-sexual, such as unsafe healthcare and cosmetic practices. If HIV infection in mothers was prevented, mother to child prevention would be taken care of.

Mother to child transmission programs often forget the 'mother' element, aiming to improve headlining child related (and Millennium Development Goals related) indicators and giving relatively little attention to the maternal indicators. One of the best ways to improve the health and welfare of a child is to do so for the child's mother first. Indicators are a means to an end, though you wouldn't think that sometimes.

Making blood transfusions safe is the august group's number five, which is good to hear. But most national AIDS strategic plans already claim to have achieved this. They haven't, but cost benefit estimates based on the questionable figures UNAIDS provides for HIV transmission through contaminated blood are not going to be reliable anyway. Similar remarks apply to their number six, making medical injections safe, which is only considered 'good', as opposed to the 'excellent' first five interventions.

But all 18 of the interventions considered, from the most cost effective to the least, suffer from the same problem: they all assume that HIV transmission occurs in a social vacuum. And the academics in question are supposed to be considering HIV as a sexually transmitted infection! No disease is independent of the people it infects, the hosts, no matter how it is transmitted (or even if it is non-transmissible). And no disease is independent of the environment in which it is transmitted.

The interventions that aim to reduce HIV transmission by making blood transfusions and medical injections safe would have an impact beyond HIV alone. This could also reduce nosocomial transmissions of hepatitis B and C, a large percentage of which is transmitted in hospitals and clinics. These measures could also reduce other nosocomial transmissions, such as bacterial infections.

But otherwise, the entire exercise carried out by Bjorn Lomborg, his Nobel Laureates and some other assorted geniuses seems like an expensive waste of time. Perhaps it's good that the Danish Government is cutting funding to their research. But let's hope they divert the funding to broader health projects, ones that certainly don't target a single disease or type of disease; perhaps they could look at health systems strengthening.

One of the biggest dangers of many of the most popular HIV and other sexual and reproductive health interventions is that they are carried out in badly equipped and funded health facilities, often staffed by badly paid and badly trained personnel. Worse still, many health procedures are carried out in makeshift facilities, by people with no training at all, or even in people's own homes.

Before health programs can be successful, health facilities need to be accessible and safe. There is a need for funding that goes way beyond that of HIV, or sexual and reproductive health more generally. But even HIV and sexual and reproductive health issues can not be addressed until health facilities are vastly improved.

As Gisselquist points out, HIV is transmitted through memorable events, be they sexual or skin-piercing. Despite all the reports of 'African' sexual behavior, most people remember a fair bit about their own sex lives, with whom they had sex, when, how often, what kind of sex, etc. Stigmatizing the whole issue of HIV by branding Africans as sex obsessed doesn't help collect information about sexual behavior, but data could be collected.

The problem is that researchers tend to disbelieve Africans when they list no or very few partners, no or very little sex, relatively low levels of risky sex, little sign of promiscuity, an adult attitude towards sex and reproduction and a humane attitude towards sexual partners, friends, family members and children, especially their own children.

Researchers tend not to ask at all about non-sexual risks, which often carry a far higher probability of transmitting HIV and other blood borne diseases; some of these risks are extremely common. For example, it is rare to find data on shaving other cosmetic practices, dental visits, hospital and clinic visits and various medical procedures that could involve the use of unsterile equipment. Or if they ask, they don't seem to report the responses.

Many HIV positive people would be able to remember most or all the events that could have led to their infection, if only they were asked. Many would be able to cite such events, even if not asked, if only they were taught to watch out for those risks as assiduously as they are taught to watch out for relatively low risk sexual experiences, such as penile-vaginal sex with their only sexual partner.

The review identifies 44 randomized controlled trials, following more than 120,000 adults in Africa which saw over 4,000 infections during the course of the trials. But interventions that assume almost all HIV transmission to be sexual, even where the intervention may reduce transmission, will likely fail to identify the circumstances that give rise to massive rates of transmission only found in some African countries. These interventions all failed in this respect.

In general, where people were said to have been infected sexually, no attempt was made to test their partner or to identify a sexual partner who was also HIV positive. No effort was made to identify non-sexual risks, either. So the UNAIDS advice to "know your epidemic" in order that you may "know your response" can not be followed, even by UNAIDS.

It is not even possible to carry out further analysis of data because it was either not collected or has not been made available by researchers. And the review raises a number of serious ethical issues in the RCTs. Six of the studies did not warn participants that their sexual partners were HIV positive, which meant they could have avoided a serious risk of being infected. It is not known how many people became infected in this way.

The review recommends that African governments should insist on trials being carried out ethically, particularly by following protocols that would be required in the countries funding the research. In addition to being carried out ethically, data that is relevant to risks should be collected and made available to the research community. And all data that is relevant to HIV risk should be collected, not just sexual risk behavior.

The findings of this review are truly shocking. That Western governments can carry out such research, knowing the effect they are having on innocent people, is sickening. The fact that African governments allow these trials to take place under such conditions is also horrifying, though it does not exonerate the Western governments involved.

But the most frightening thing of all is that these trials have taken place with the full participation of some of the most highly educated people, using the latest research and equipment, with some of the biggest health research funds ever awarded, over so many person years....

Far from reducing HIV transmission or finding out why transmission is so extraordinarily high in some countries, these randomised controlled trials appear to have allowed avoidable HIV transmission to occur, perhaps even hastened transmission in some instances. This is arrogance on an appalling scale, the consequences of which are deadly. And all done in the name of HIV prevention.

The authors are particularly critical of disease-specific interventions or 'vertical approaches' to healthcare. Many of these, upon singling out a particular disease, such HIV, TB or malaria, proceed to expend copious quantities of money and other resources on these, to the exclusion of any attempt at addressing the reasons why these diseases are spreading.

The money is generally spent on drugs and other commodities, items that require people to be infected with the disease in question before being of any use. Anything that reduces the underlying health risks that people face, such as water, sanitation and hygiene, nutrition and food security, literacy, empowerment, poverty, etc, is ignored.

It's not a new discovery that drugs are a necessary, but by no means sufficient means of eradicating a disease. No disease has ever been eradicated by drugs alone and it seems unlikely that one ever will. Technical solutions, such as mass roll-out of drug therapies (antiretroviral treatment, Pre-exposure Prophylaxis, microbicides, male circumcision, vaccinations, and the like), are expensive. But if there is little or no health infrastructure, each vertical program needs to create its own infrastructure. This is inefficient and can contribute to what could be called the 'Bill Gates effect': everyone gets a pill but no one gets clean water with which to swallow it.

A far better way of characterizing health, which would have given rise to a more 'horizontal' approach, was that enshrined in the Alma Ata Declaration on Primary Health Care of 1978. This defines health as "a state of complete physical, mental and social wellbeing, and not merely the absence of disease or infirmity", involving "the action of many other social and economic sectors in addition to the health sector."

The date of the Alma Ata Declaration is particularly poignant because HIV, which had probably been spreading for decades, was only identified a few years later. Luckily, it was identified in a rich country, as it might have remained unnoticed for many more years if it had only infected people in developing countries.

Also poignant is the fact that the Declaration's definition of health was quite contrary to what became the dominant health paradigm, vertical programming. With vertical programming, disease is the measure of health; if you don't have a disease, you don't receive any of the benefits of health programs. Indeed, if you don't have the right disease, your health or lack of it is of no relevance.

The paper discusses the Gates Foundation approach to HIV and a handful of other headline grabbing diseases. This approach excludes any consideration of the conditions people live in, which allow these diseases to infect and affect so many. It also notes the shocking fact that two thirds of the Foundation's HIV/AIDS funding goes to vaccine research, which is labeled "preventative".

Even if a vaccine were developed and were made available to countries where HIV prevalence is highest, it is unlikely to prevent HIV transmission to any great extent. First, HIV prevention programs need to be able to identify who is most at risk of being infected. Currently, the majority of people infected in countries like Uganda, Kenya and Tanzania are those who would be thought least likely to be infected, those who don't engage in 'high risk' sexual behavior.

The paper discusses many vital issues in public health and development but I'll finish this posting with the authors' observation that "a usually unmeasured negative consequence of aid is the increase in nosocomial (hospital acquired) infections that can accompany immunization programs", and contaminated injections in general. In 2000, it was found that nearly 40% of injections were given with reused equipment and "caused an estimated 21 million HBV infections, two million HCV infections and 260,000 HIV infections, accounting for 32%, 40%, and 5% [of all transmission].”

HIV, like all diseases, is not independent of the conditions in which people live and spend much of their lives. That is precisely why health is "a state of complete physical, mental and social wellbeing, and not merely the absence of disease or infirmity".

How cruelly ironic it is that what could have been the most important and well timed decision about health ever made was replaced with a decision to view health as a commercial opportunity. As a result, big money only goes into that which allows the big players, the global pharmaceutical and healthcare industry, big philanthropy and NGOs, academia and international health institutions, to continue to grow and prosper.

Thursday, October 6, 2011

Making HIV testing mandatory in all health facilities is said to be under consideration by Kenya's National Aids Control Program (NASCOP). Mandatory testing is not currently permitted under Kenyan law. However, people seem confused about what is currently permitted, some people thinking they have to comply with whatever a health facility worker requests and others thinking a test is mandatory under certain circumstances, such as pregnancy.

It will be very hard now to claw back years of ground lost by insisting that 80-90% of HIV is transmitted through heterosexual sex in African countries. But this is what will have to be done to reduce the stigma that still surrounds the virus. It is this very insistance about African sexual behavior that gives rise to the stigma.

Health providers may worry that people will lose confidence in them, and indeed they may. But continuing to lie about sexual transmission and refusing to investigate the relative contribution of non-sexual transmission to HIV epidemics will not help to solve the problem. If health services are to be trusted, they have to find a way to reverse the years of dishonesty. Making HIV testing mandatory, and especially arguing for it on the basis of the same old lies, will be counterproductive and dangerous.

Many of the problems that arise for large scale health programs, including the extremely well funded HIV related ones, stem from a lack of sustainability. Several countries have run out of drugs at various times. Most lack the capacity to monitor for drug resistance, loss to follow up and various other problems. If more people are tested under current conditions, sustainability will be further reduced.

The best way to reduce stigma and allow people to feel less apprehensive about being tested for HIV is to come clean about the relative contributions of sexually and non-sexually transmitted HIV; we don't yet know the relative contributions. Investigating possible outbreaks of healthcare transmitted HIV would go a long way towards reducing people's fears, which may be quite legitimate.

HIV is more difficult to transmit through penile-vaginal sex, yet prevlance rates are much higher than those found for syphilis. But also, syphilis prevalence is similar among men and women. HIV prevalence is far higher among women than men in Kenya, overall, and more than five times higher in one large tribal group. Syphilis prevalence does not differ by urban/rural residence whereas HIV prevalence tends to cluster in urban areas. HIV prevalence in some rural areas is very low indeed.

While syphilis prevalence is highest among HIV positive men, HIV wasn't even found to be a significant risk factor for women. Syphilis prevalence tends to increase with age in men and women, whereas HIV prevalence tends to increase at a later age in men than in women, rising to higher prevalence rates among women than men, before dropping rapidly in older age groups among both men and women.

Syphilis prevalence is higher in Yaounde, Cameroon than it is in Kisumu, Kenya, although HIV prevalence in Yaounde is relatively low and in Kisumu it is very high. In South Africa, syphilis prevalence has declined far more rapidly than HIV in a similar period among antenatal clinic attendees.

Syphilis prevalence of over 10% has been recorded among Kenyan sex workers, among whom high STI rates could be expected. However, figures of 70-80% claimed for HIV prevalence among sex workers in the 1980s in Kenya and in the 1990s in Tanzania have never been recorded for syphilis, anywhere. In fact, in some countries HIV prevalence is not particularly high among sex workers unless they face additional risks, such as intravenous drug use.

Poorer men, and poorer women to a lesser extent, are more likely to have syphilis, as are men with lower levels of education. HIV prevalence tends to be higher among wealthier quintiles and among those who have higher levels of education, in Kenya, Tanzania and other countries.

It is worth bearing in mind that high prevalence of STIs does not mean that people necessarily engage in unusually high levels of unprotected sex. It does mean that health services, particularly sexual and reproductive health services, are inadequate.

I am concentrating on the differences between syphilis and HIV, but there are few remarkable similarities. I don't wish to deny that HIV is sometimes transmitted through heterosexual sex, just to question the extent of such transmission. Because, if transmission patterns are not very like those for syphilis, it would be a mistake to characterize HIV as an STI and design HIV prevention interventions accordingly.

Sunday, October 2, 2011

Up to now, UNAIDS' method of verifying their data has been the equivalent of printing out lots of copies of their reports and concluding that, because they all say the same thing, they must be true. First on the chopping block should be the HIV Modes of Transmission analyses (MoT), which purport to estimate the relative contribution of various routes of infection, sexual and non-sexual. In reality, the data used is a mishmash of guesswork and hot air.

They are mercifully brief in their analysis, though they are far from merciful to Bollinger. They question if analyses such as Bollinger's can "really provide estimates that are sufficiently transparent, valid and reliable at the country level", and express serious doubts about the value of her work.

Baltussen and Hontelez don't feel that the models Bollinger uses "reflect the actual epidemiology" in the countries in question. Thankfully, they also doubt the adequacy of the "estimates of the relative contribution of each transmission route to the overall epidemic". In particular, they question the validity of the MoT reports used.

These researchers also examine the claimed impact of various HIV prevention interventions and remain unconvinced. They even have doubts about the costing data used for Bollinger's cost/benefit analysis. They point out that all these limitations are "inherent to the task at hand and therefore virtually inevitable". Baltussen and Hontelez do well to raise the issue of the usefulness of such data; yet much of UNAIDS' HIV policy is based on it.

The list of limitations goes on and on. While it is not one of the authors' conclusions, every criticism of Bollinger's offering is a criticism of UNAIDS, the HIV industry as a whole, and much of the HIV literature that has launched a thousand failed interventions per year for the last 20 years or so. The 'successes' among these interventions are based on grotesque overestimations that remain unquestioned even when program after program has failed to deliver the goods.

Despite unearthing all these limitations in the work of Bollinger, and much of the work of the HIV orthodoxy, the authors agree with Bollinger's conclusion: "that interventions to reduce non-sexual transmission of HIV are generally economically attractive". Which is great, as long as the "absence of comprehensive data" that Baltussen and Honetlez note is also rectified.

I'm still mystified as to the lack of consensus between the first and second paper commissioned by Lomborg and his gang. However, I'm not complaining. It makes a pleasant change to see researchers challenging each other rather than patting each other on the back. A few more papers like this and UNAIDS may even have to revise their lynchpin: the assumption that most HIV transmission in African countries is through heterosexual sex.

At less than five pages, Baltussen and Honetlez's paper is highly significant. But what influence will RethinkHIV have on the HIV orthodoxy? UNAIDS has discredited and branded anyone who has dared to challenge their racist, sexist and highly destructive stance. Will they do the same to these authors, or even to RethinkHIV? Perhaps Lomborg has miscalculated his credibility; HIV celebs gain their strength by supporting the orthodoxy, not by challenging it.

Incidentally, Lori Bollinger says elsewhere in a throwaway remark "the work we do is not about numbers and equations, but about people." But it is about numbers and equations and it is not about people. When Africans are asked about their sexual behavior, their answers show that they are human beings. They have similar sexual behaviors to other human beings. But researchers conclude that Africans 'underestimate' and/or 'overestimate' in their answers, effectively calling them all liars. (Thank you to Dr David Gisselquist for the Bollinger citation.)

Researchers tend to assume as a starting point that African sexual behavior (yes, apparently Africans are all the same) explains extremely high prevalence of a virus that is difficult to transmit sexually. Without this assumption their research is unlikely to be funded or published. But this has resulted in the current impasse in HIV prevention. The way forward is to investigate non-sexual HIV transmission but to use empirical data, not the stuff UNAIDS calls data.

[For more about non-sexual HIV transmission modes, such as unsafe health care and cosmetic services, visit the Don't Get Stuck With HIV website]